Provider Demographics
NPI:1336996636
Name:HEART AND SOUL THERAPEUTIC MASSAGE
Entity type:Organization
Organization Name:HEART AND SOUL THERAPEUTIC MASSAGE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:MICHELLE
Authorized Official - Middle Name:
Authorized Official - Last Name:ROUDEBUSH
Authorized Official - Suffix:
Authorized Official - Credentials:LMT
Authorized Official - Phone:765-662-8222
Mailing Address - Street 1:111 E GRANT ST
Mailing Address - Street 2:
Mailing Address - City:LA FONTAINE
Mailing Address - State:IN
Mailing Address - Zip Code:46940-9238
Mailing Address - Country:US
Mailing Address - Phone:765-662-8222
Mailing Address - Fax:
Practice Address - Street 1:518 S BALDWIN AVE
Practice Address - Street 2:
Practice Address - City:MARION
Practice Address - State:IN
Practice Address - Zip Code:46953-1373
Practice Address - Country:US
Practice Address - Phone:765-662-8222
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-05-03
Last Update Date:2024-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Single Specialty